Healthcare Provider Details

I. General information

NPI: 1215184643
Provider Name (Legal Business Name): AMY RENEE RUSSELL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AMY RENEE MOORE

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 N MAIN ST
CRESTVIEW FL
32536-3541
US

IV. Provider business mailing address

369 N MAIN ST
CRESTVIEW FL
32536-3541
US

V. Phone/Fax

Practice location:
  • Phone: 850-332-2589
  • Fax: 850-398-8277
Mailing address:
  • Phone: 850-398-6963
  • Fax: 850-398-8277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9226261
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberARNP9226261
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: